Health Insurance Service

1. Personal Information

Government-issued ID (Passport, State ID, or Driver’s License)
Full legal name
Date of birth

4. Household Information

Names and dates of birth of family members
SSN or ITIN (if available)
Relationship (spouse, child, etc.)

2. Proof of Address

Utility bill
Lease agreement
Official mail with your name and address

5. Income Information

Recent pay stubs
W-2 or 1099 forms
Self-employment income
Unemployment or Social Security income

3. IImmigration or Residency Status (if applicable)

U.S. Visa
Green Card
I-94 form
Work permit (EAD)

6. Additional Information

Employer information (if offered insurance)
Bank account details (for monthly payments, if required)

Note: These documents help determine your eligibility, monthly premium, and any government subsidies you may qualify for.

Before You Apply

Please upload all required documents below
Our licensed agents will review your information and contact you to complete your enrollment.

First name

Last name

Phone

Submit your questions here

File upload

Disclaimer *

By submitting this form, I agree to provide my information to Amallaz insurance and give permission to be contacted by phone, text, or email about insurance-related opportunities and services. I understand message and data rates may apply, and I can opt out at any time.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.